Tackling challenges as a team on a multifaceted unit.

The nature of surgical and postanesthesia care planning is unpredictable. Although the schedule looks one way on paper, it can easily morph into something completely different due to emergency surgeries, differing levels of acuity, and "add ons" or complications.

"Flexibility is the key to success in this area. It's not unusual to be asked the day before and the day of to change where and when we're scheduled to work," said Geryll Hill, BSN, RN, a staff nurse on the post anesthesia care unit (PACU) at Children's Hospital & Research Center in Oakland. "But we flex and adapt so that little fires don't ignite into bigger ones. We are the patient advocates who pay attention to all the minutiae that could add up to potential risks. And we've learned to become flexible in pulling from one area to accommodate another."

That's no easy task when your "unit" consists of several locations not all in the same building. These PACU nurses handle about six different jobs with varying shift times, and they need to switch gears to cover two completely different types of PACUs, an anethesia preview clinic, two separate preoperative areas and an off-site radiation center.

Shared Governance

The PACUs at Children's Hospital involve a wide range of procedures, such as craniofacial surgery, neurosurgery, orthopedic surgery and cardiac catheterizations seen in the main PACU, and less acute surgeries in the outpatient PACU. The variation seen day to day forces the group to rely heavily on good communication.

"Because our unit is separate in many ways, with two different recovery rooms, it can be challenging because one person might not know what the other person is doing in the other area," said Janet Schofield, RN. "We strive to keep our communication open to make sure everyone knows what's going on with their teammates that day. If communication falls apart, what we're doing that day falls apart."

Communication goes a long way when forming a cohesive vision for the unit as well. Each team member has a role in addressing potential problems and confronting issues that need to be addressed.

"We've been fortunate because our manager allows us to help determine how we run our unit. So we have some freedom and autonomy," Schofield said. "We've come to this place where we're able to make decisions that we weren't able to make in the past because of too much structure."

One example of the good that can come out of this proactive involvement by each staff member is the brainstorming that led to a new charge nurse role to take care of the moment-to-moment changes among all the different PACU areas.

"We discussed what that person should do and our manager allowed us to reinvent the leadership structure by creating a charge nurse role for all the areas and team leaders in the PACU units," Hill said. "Our communication among all the units has been greatly enhanced as a result, and we feel like we have come close to a type of shared governance that is very gratifying."

The ability to provide input in how the unit is run allows each nurse to be proactive about blending her own strengths with her teammates' to provide the best care for patients.

"I appreciate how our team takes ownership of the recovery room; we brainstorm ways to improve our care and our working conditions," explained Claudette Beauchamp, RN. "We keep an agenda list posted to add our ideas for the next team meeting, which we call 'WE meetings.' The meetings get quite spirited but I always feel we accomplish our goals."

Heading Off Problems

The WE meetings are scheduled quarterly and are held in people's homes.

"I've never figured out if the WE stands for work environment or simply the WE as a group," Hill joked. "But these meetings have been very productive and provide a constructive outlet to deal with work challenges. They allow us to head things off before they snowball into something that might be a bigger problem in the future."

Topics discussed can range from reminding people to keep a certain work area organized to brainstorming a new leadership position.

"This talented group of nurses brings so much to the PACU," Beauchamp said. "I'm amazed at the number of years of experience that surround me every day. But even with all of that experience, we are all willing to work together, learn from each other and adapt as needed."

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